EHRs Behind Bars: Progress and Barriers
Although electronic health records are widely seen as a way to improve care coordination and boost patient outcomes, they are underutilized in the treatment of some of the individuals who stand to benefit the most: jail inmates.
Background on Inmate Health Care
The nation's more than 3,300 county, city and local jails process about 11 million admissions annually. Jail populations are highly mobile, with an average weekly turnover of 60%, and are largely uninsured with high rates of chronic diseases, mental illness and substance misuse.
Since the 1976 Supreme Court decision in Estelle v. Gamble, jails have been legally required to meet the medical needs of inmates in accordance with community standards of care. Jails that fail to meet those needs could be held in violation of the Eighth Amendment prohibition against cruel and unusual punishment.
However, jails historically have not been recognized as providers of health care and tend to be left out of major policy discussions, such as the 2009 passage of the HITECH Act, which created the meaningful use electronic health record incentive payment programs.
In a June issue brief, Ben Butler, CIO at Community Oriented Correctional Health Services, wrote, "In an ideal world, the health care [inmates] received in jail would be connected to the health care that they receive in the community, both to ensure continuity and avoid duplication of care." However, he noted that the "ideal is not yet reality," adding that "most health care provided in jail resides in a black box."
Butler argued that health IT, such as EHRs and health information exchange, are key to taking jail health care out of the black box and connecting it with community care.
Benefits to Jails Adopting EHRs
Across the country, jails increasingly are exploring EHRs as a way to replace their old paper-based record systems and are examining ways to better connect and share data with community providers.
Some jails -- such as in Hampden County in Massachusetts -- have developed their own EHR systems, while others have purchased and implemented systems developed for non-correctional settings.
In 2005, the Orange County Corrections Department in Orlando integrated an EHR system into its newly launched jail management system. The system, according to a Health Affairs article, significantly improved documentation, patient tracking and triage at the jail in part by allowing officials to view repeat offenders' medical records during admission.
Meanwhile, in Oregon, the Multnomah County Health Department in 2012 implemented an EHR system at the two jails it oversees, allowing them to share data with local health care clinics and hospitals that had adopted the same system.
The New York City Department of Health and Mental Hygiene -- which oversees the second largest jail system in the U.S., consisting of 12 jails with about 80,000 annual admissions -- began implementing an EHR system in 2008. The jails use the EHR system throughout an inmate's stay, including discharge, and total about 30,000 documented patient encounters per month.
However, the department made various modifications to the EHR system to better suit the jails' unique needs, such as being able to handle:
- Mental health encounters;
- New admission intakes;
- Newborn nursery;
- Sick calls; and
- Solitary confinement rounds.
A study published in the Health and Human Rights Journal found that among other things, EHRs improved the New York City jail system's ability to detect and provide care for patients injured during their stay and those with mental illnesses. The system also enabled the jails to identify trends in injuries or incidents among inmates and improve the speed and efficiency of response efforts. Further, the EHR system allowed jail staff to review patient care and ensure that appropriate care was delivered.
Specifically, the study outlined three ways the EHR system contributed to improved inmate safety and care:
- Being able to easily alter data that are collected on patient care, treatment and abuse;
- Connecting to a health information exchange so inmate care can be continued and monitored by community providers after release; and
- Producing reports based on patient clinical outcome, location, profile and time.
Gary Steiner -- director of correctional, behavioral and public health care products at NextGen, an EHR vendor -- said the ability of EHRs to improve documentation is particularly important to jails facing lawsuits from inmates over care.
Other benefits EHRs offer jails include:
- Better care coordination between providers, including mental health providers;
- Cost-savings by reducing the number of unnecessary tests and procedures;
- Cutting the amount of burdensome paperwork;
- Improving patient safety and care;
- Influencing policy through more accurate, timely reporting to federal and state agencies; and
- Reducing population health disparities through greater health information exchange.
Obstacles to EHR Adoption in Jails
Despite the many benefits, EHR adoption among jails continues to lag.
Steiner noted that as of June 2013, only about 18% of jails had some form of EHR system.
There are numerous challenges that could be contributing to the low EHR adoption rate among jails, including:
- Budget and cost restraints;
- Difficulty integrating EHRs with existing systems;
- Staff training; and
- Tailoring EHRs to meet jails' unique needs, such as accepting mental health care providers' text-based notes.
Steiner noted that most jails operate on small margins of 2% to 3% and that the cost of implementing an EHR system can vary significantly depending on the size of the jail system, the number of providers and the level of connectivity desired. He added that because of those small operating margins, jail systems sometimes struggle to even backfill employees who need to be trained on how to use the new system.
Meanwhile, a New York City Department of Health and Mental Hygiene spokesperson in an email said the "primary challenge" in adapting EHRs to better fit jails' needs was "deciding what information about vulnerability is important and then collecting it when our providers care for a patient with a specific health outcome."
The Meaningful Use Program and Jails
When the HITECH Act was passed in 2009 as part of the economic stimulus package, lawmakers saw it as an opportunity to encourage EHR adoption, but jails were left out.
According to a notice on the National Sheriffs' Association website, providers who practice in jails were not considered eligible to receive incentive payments because at least 30% of eligible providers' patient encounter volume had to be reimbursed by Medicaid, and jail inmates cannot use their Medicaid coverage while in jail.
However, stakeholders argued that jails stand to benefit from many of the objectives, requirements and goals of the meaningful use program.
Recognizing those benefits, CMS in 2012 released a new rule that expanded the eligibility requirements to enable correctional facilities and jails to participate in the Medicaid meaningful use program. The updated requirements allow providers to participate in the Medicaid program if 30% of their patient encounters involve patients enrolled in -- rather than reimbursed by -- Medicaid.
But nearly two years later, just one jail system has successfully attested to meaningful use, according to an Office of National Coordinator for Health IT spokesperson.
In his June issue brief, Butler noted that one of the biggest challenges facing jails that wish to attest to meaningful use is the program's requirement for patient engagement. Under Stage 1 and Stage 2 of the meaningful use program, eligible professionals are required to provide at least 50% of their patients with clinical summaries and electronic access to view and download their medical records.
He said that jails have such high turnover rates that it is hard to get an inmate the proper summary before he or she leaves the system. In addition, Butler noted that it would be "highly problematic" for an inmate to download their EHR and, generally, it would not be permitted for that data to be transmitted to their provider.
In an interview with iHealthBeat, Butler said that sheriffs typically resume ownership of patient records generated during an inmate's stay. In his issue brief, he added that it would be highly unlikely for most sheriffs to allow former inmates to access their IT systems to view their records after release.
Other obstacles jails face when attempting to attest to meaningful use include:
- Adapting EHR products to meet their unique needs;
- Hiring providers that meet license requirements for the program; and
- State politics, such as decisions not to expand their Medicaid programs under the Affordable Care Act, which make it difficult for eligible professionals to meet the 30% threshold to participate in the Medicaid meaningful use program.
Under the Medicaid portion of the meaningful use program, providers have an Adopt/Implement/Upgrade -- or AIU -- option in their first year of participation. Rather than meeting meaningful use criteria, Medicaid providers can attest to:
- Adoption of certified EHR technology;
- Implementation of EHRs; and
- Upgrading EHR technology.
Those providers still must meet meaningful use criteria in subsequent years.
Butler noted that EHR adoption in jails is still in its infancy and the last year to attest for Medicaid's AIU is 2016. He added that meeting the 2016 deadline would be "a heavy lift" for many jails, making it unlikely that they will get on board in time.
Although the evidence suggests that jails will not be able to ramp up their health IT systems in time to qualify for meaningful use incentive payments, both Butler and Steiner agreed that the program has helped to establish a new standard for care delivery in jails and could help shape future initiatives to improve data exchange among jails and community providers.
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